# NTSB LAX89FA277: Piper PA-23-250, N4838P, Lake Tahoe, CA, August 14, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: August 14, 1989, 11:12 local (18:12 UTC)
- Place: Lake Tahoe, CA
- Location: 38.9282° N, 119.9810° W: Placed by OpenAirDocs: center of South Lake Tahoe, CA, within about 9 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=38.9282&lon=-119.9810&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report September 9, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 26240
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX89FA277
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26240/pdf
- Page: https://openairdocs.org/ntsb/LAX89FA277

## Probable cause

DISABLEMENT OF THE STABILATOR FLIGHT CONTROL SYSTEM.  A CONTRIBUTING FACTOR WAS:  INADEQUATE MAINTENANCE.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Airframe/component/system failure/malfunction, approach
  - flt control syst,stabilator control cable/rod - binding(mechanical) (contributing factor)
  - maintenance,annual inspection - inadequate, other maintenance personnel (contributing factor)
- Loss of control - in flight, descent - uncontrolled
  - flight control,stabilator - jammed
  - flt control syst,stabilator control - disabled (cause)
- In flight collision with terrain/water, descent - uncontrolled

## Analysis

APPROACHING THE ARPT, THE PLT RECEIVED LDG INSTRUCTIONS. SECONDS LATER, HIS TRANSMISSIONS WERE ABRUPTLY TERMINATED. WITNESSES OBSERVED THE ACFT ABRUPTLY NOSE OVER & DESCEND INTO WATER AT A HIGH RATE OF SPEED. IT FRAGMENTED UPON IMPACT & IMMEDIATELY SANK. THE ACFT HAD RECENTLY UNDERGONE MAINTENANCE INVOLVING THE REMOVAL & INSTALLATION OF ITS WINGS, & INSTALLATION OF AN AUTOPILOT & ELECTRIC TRIM. FOLLOWING THIS WORK, THE ACFT WAS FLIGHT TESTED. DURING THE TEST, THE PLT EXPERIENCED A LOSS OF CONTROL & THE ACFT PITCHED DOWN IN A MANNER SIMILAR TO THAT DESCRIBED BY WITNESSES TO THE ACCIDENT. EXAM OF THE UPPER STABILATOR PULLEY ASSEMBLY REVEALED THAT ITS RESPECTIVE CONTROL CABLE HAD BEEN WORKING AGAINST THE SIDE OF THE PULLEY. THE PULLEY WAS FRACTURED, & THE CABLE HAD BECOME WEDGED IN THE PULLEY, WHICH (IN TURN) HAD BECOME WEDGED AGAINST THE SIDE OF ITS SUPPORT BRACKET. THIS ACTION RESTRICTED STABILATOR MOVEMENT.

## Aircraft

- Registration: [N4838P](https://openairdocs.org/deregistered/N4838P-2013-04-18), registration cancelled 2013-04-18, S/N 27-408, built 1961 (OpenAirDocs)
- Reported make and model: PIPER PA-23-250
- Registry model: [Piper PA-23-250](https://openairdocs.org/model/piper-pa-23-250) (registry code 7102308) (OpenAirDocs)
- Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 27-408
- Airframe hours: 2554
- Engines: LYCOMING O-540-A1D5 250 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Registered owner: John W. Buchanan, Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 2, 1989, 25 hours before
- Departed: S21, SUNRIVER, OR
- Destination: TVL, LAKE TAHOE, CA
- Airport: TVL, Lake Tahoe

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 66; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 2,091 total, 680 in this make and model, 12 in the last 90 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 350° at 8 knots
- Visibility: 50 statute miles
- Lowest ceiling: none
- Temperature: 72 °F, dew point 39 °F
- Altimeter: 30.00 inHg
- Observed at: TVL, 21 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 19890814029129A](https://openairdocs.org/incident/19890814029129A), Aug 14, 1989: Piper STCPA23, South Lake Taho, CA, Destroyed, 2 fatal. Observed to pitch up,stall and dive into lake. Elevator pulley broke,had been rubbing on housing. Prior pitchover.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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